Why does the situation described pose an ethical problem for
the people involved, as opposed to a practical, legal, or technical problem?
Explain what ethical principles are relevant to the case, how they apply
to the case, and whether they conflict with each other. Are the ethical
principles you mention generally accepted or controversial?

It is the moral responsibility of doctors to do what is best for their
patients. There are 3 individuals involved here, mother, daughter, fetus,
and their interests may conflict. So we need to work out what is best for
each. We need to decide what the doctor's responsibility is to relatives
of his/her patient. Clearly the mother is not a patient of the doctor in
this context. The daughter clearly is a patient. Some would argue that
for pregnant women, the fetus they carry is also a patient of the doctor.

We also need to work out what the rights are of the mother, daughter
and fetus. Note that people can have a right to do what is not best for
them. The daughter may have a right to be free of medical intervention
even though she would be better off if she had an abortion. The right of
the mother to decide what happens to her daughter, the right of the fetus
to life, and the right of the doctor to refuse to do what the mother asks
are all in question.

Note that justice is hardly involved in this situation at all. Justice,
as we use the term here, is to do with the distribution of limited resources.
The main way that justice enters into this case is in who should pay for
the abortion if the daughter has one, and whether the mother should get
more help from the state to look after her daughter and her possible grandchild.
One could also ask whether there should be have previously been more social
support for such a family, because if there had been, then this difficult
situation might not have happened in the first place. But that's a larger
issue that the doctor probably doesn't have the time to think about given
his/her busy schedule.

Note that it is inappropriate to discuss this case in terms of the daughter's
right to autonomy. She is severely mentally retarded, and so probably has
a mental age of 5 or less. While such a person is competent to make some
minor decisions for herself (clothes, food, and other day-to-day details)
she does not have the comprehension to make more important decisions. In
particular, she does not understand the outcome of sex, and she does not
understand reproduction. One can only have a right to do X if one can want
to do X and if one is able to do X. So the daughter does not have the right
to control her life to extent to decide to have a child, because she doesn't
understand that decision.

(This is different from saying that a person only has a right to do
X if one is competent to cope with the consequences of X. It is much more
controversial to say that young teenagers and the mentally ill do not have
the right to have babies if they won't be able to look after those babies
once they are born. It is also different from saying that the daughter
in this case does not have a right to have sex. She is physically mature,
and she can understand and enjoy sexual pleasure. We might have no right
to deny her that opportunity. Of course, the difficulty is how to let her
enjoy that right without getting pregnant.)

The fundamental issue here is whether we have a right to force the daughter
to have an abortion. She would be unlikely to understand what an abortion
is, and given her communication difficulties as a result of her deafness,
we obviously cannot get informed consent from her. We do not have a general
right to do whatever we like to incompetent people. Legal guardians have
the right to order medically necessary treatments. But obviously parents
and legal guardians do not have the right to order just any medical procedure.
(For instance, what would we think of a parent who decided that his child
should have a large tattoo on her arm?) Parents do not have the right to
make decisions to order bodily invasive procedures which are clearly against
the best interests of the child. That is a form of abuse.

So a major issue here is whether the abortion is in the best interests
of the daughter. Even if it is, it might still not count as being medically
necessary. We do know that an abortion carries with it less risk
of complications leading to death than pregnancy. However, it is stretching
it to say that this makes abortion medically necessary, since the actual
chances of death are so small in the first place. If it were medically
necessary in this case, it would be medically necessary in all pregnancies!

A much better case for the medical necessity of abortion could be made
from the other particular circumstances of the daughter. She is wheelchair
bound and severely retarded. We would want to find out whether being restricted
to a wheelchair or a bed would make the pregnancy significantly more dangerous
for her. (Maybe due to a possibility of blood clots? She would also probably
have to have a C-section to deliver.) But it is the distress that she experienced
as a result of the pelvic exam that is the biggest clue to the danger of
the pregnancy for her. She would find the changes in her body very alarming,
especially when she has to go through many more pelvic exams and other
medical treatments. Imagine a 4 or 5 year old blind wheelchair-bound girl
going through pregnancy! The experience would be more than unpleasant or
inconvenient for her -- it might cause her psychological damage. So the
best case we can make for the medical necessity of the abortion is the
threat to her mental health.

(Who gets to decide what counts as the daughter's best interests? This
is a much debated issue for the never-competent. In the case of people
who are now incompetent, in a coma for instance, but were previously competent,
we can try to work out what they would have wanted from their expressed
views or the way they lived their lives. This is called "substituted judgment."
But for never-competent patients, this makes no sense, because they never
had and never could have an opinion about such matters. So we have to use
someone else's value-scheme. Should this be the guardian's value-scheme,
or the doctors', or the state's? What standards of evidence are appropriate
here? This is a fertile ground for philosophical, moral and legal discussion.)

In the case of abortion, we also need to think about the moral rights
of the fetus. This is complicated by the fact that it is probably the product
of incest. (Since the daughter's retardation was a result of a brain tumor
removed at birth, there is no reason to think that her condition is hereditary.)
Some might say that even if the fetus has a right to life, in this case
it would probably be better off not being born, because of the handicaps
it could have and the social circumstances it will be born into -- i.e.
it would be better off dead. However, most people these days tend to say
that no matter how burdensome life is, it is still worth living.

Whether abortion is morally permissible is of course a topic of controversy.
As an ethicist advising on this case, it is not my place to insert my own
personal opinion here. The issue is whether the mother and the doctor have
the right to make that decision when it is the daughter who will go through
the procedure. Abortion rights are normally based on a woman's right to
choose what happens to her body. But here the woman is not making the decision;
others are. This difference makes abortion especially problematic, especially
if it were not medically necessary. The doctor certainly has the right
to refuse to do the abortion if s/he is morally uncomfortable with it.
The hospital as an institution also has no moral obligation to find a doctor
willing to perform the abortion. So the decision is up to the individuals
involved. If they refuse to grant the mother's wishes, then she will probably
go elsewhere and ask again, and she might even try to get the abortion
performed illegally.

What are the main options available to the individuals involved?
You should only include realistic options, and you may find it useful to
explain why the options you are setting out might be useful. You should
think creatively to suggest options that are not mentioned in the text.

The option of adoption needs to be explored further. Given the moral
and legal problems that could arise, adoption might be the best option.
The mother has already refused that possibility, but if the doctors made
clear they were unwilling to perform the abortion yet were willing to help
her with the pregnancy and adoption services, she might change her mind.
Often adoption agencies will pay the medical costs of the pregnancy. However,
we need to get clearer whether adoption is a realistic option. How likely
is it that a baby that is the result of incest and which consequently has
mental and/or physical disabilities will get adopted?

The mother is clearly under great strain, and if she can get more help
from social services or local charitable organizations, that should be
arranged. Her whole perspective might change if she gets more help. However,
we must also realize we are working with time constraints. The older the
fetus gets, the more morally questionable abortion becomes. Right now it
is about 13 weeks. That means that they have about 8-11 weeks left before
abortion probably ceases to be legal. (Some third trimester abortions are
permitted when the health or the life of the mother are at risk, but this
is increasingly becoming illegal. In the last few years, more and more
states have made late-term abortions illegal.)

Looking for sources of money to pay for the abortion, should that be
decided to the avenue to do down, is necessary. If the area is rural, there
are probably very few if any abortion clinics. Going to the nearest one
could involve significant travel, which might be difficult for the mother
and her daughter, especially if they don't have easy access to a car.

What legal issues are relevant to making the decision?

Obviously, if she isn't already, the mother needs to become the legal
guardian of her adult daughter as soon as possible. Appointing her guardian
would involve legal costs however, and it is pretty clear that the mother
won't be able to afford a lawyer or court expenses, unless she can get
help with them. This needs to be looked into.

As we already know, it is unclear whether or not a judge would agree
to allow the abortion. Making the case of the daughter's mental health
might be our best chance of convincing the judge, although some judges
are very uninterested in mental health issues. There are also risks in
going ahead with the abortion without explicit judicial permission. Clearly
the safest course of action for the doctors would be to tell the mother
to go away. But that would probably be morally wrong, because this family
needs help of some kind or other.

What further information would be useful in making your decision?
For example, do you need more details about the patient, his/her family,
medical procedures and the risks that they carry, or the social services
that are available? Who would you ask to get this information?

This has already been discussed above. It would be useful to contact
an expert in the health care of people with severe mental retardation to
give us advice, and we'd need to talk to the hospital lawyer. We'd want
to contact adoption agencies, social services, and local charitable groups.
But note that since this case involves abortion, we might also want to
not get too much attention from other people. The more people who know
about this case, the more danger there is that someone will make a fuss
and then if the case gets local or even national media attention, the hospital
could be damaged. It could also lead to much greater distress for the mother,
or it might lead to her getting more offers of help. It's hard to predict.

Who should be consulted in the decision-making process, and who has
the rights or responsibilities to make the final decision?

This has been discussed above. The final decision about whether the
hospital doctors should pursue the abortion option lies with them. It is
up to the mother if she decides to go elsewhere.

Consider the reported reasoning of people in the case. Is their reasoning
well-argued? Do you agree with it or not? Explain.

This has been discussed above.

What decision would you recommend? Explain why you believe this decision
is more reasonable than any other.

Whatever we do, we should try to help this family. If the individual
doctors are ready to be involved, there is a good case to be made that
the abortion is medically necessary. The hospital does take risks in performing
an abortion, and should take the advice from the hospital lawyer about
what is the legally best way to get an abortion, especially since the lawyer
will know most about the local legal situation and the probably court decisions.
But even though the procedure could be legally risky, the hospital should
not be too cowardly about the possibility of legal risk. We have to take
risks all the time, and we have insurance. If we don't go through with
the abortion, we should explore the adoption option, in combination with
getting better social support for the family.